Provider Demographics
NPI:1912878091
Name:COULOMBE, CARLY JEAN
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:JEAN
Last Name:COULOMBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLEY
Other - Middle Name:JEAN
Other - Last Name:COULOMBE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:240 E GIRARD AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:215-823-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-13
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical